Summary The purpose of this project is to demonstrate major improvements in care quality through redesign of care delivery in the University of Utah Community Clinics. The Community Clinics (CC) are a fee-for-service 10-site primary- and secondary-care system with about 50 primary care physicians, 350,000 annual visits, and 120,000 active patients. The CC have led primary care delivery reform since 2003 when we began the development and implementation of a new model of care called Care By Design (CBD). The three organizing principles of CBD are: Appropriate Access (AA), Care teams (CT), and Planned care (PC). It is within this existing system design that we will implement additional redesigns. In this project we will implement a comprehensive care management program targeted to patients with multiple chronic conditions. Our delivery redesign will include strategies for effectively managing care transitions and for aggressively screening for and treating depression, a complicating co-morbidity for many patients with chronic conditions. Our intervention builds upon and strengthens CBD in order to achieve major improvements in care quality. We will compare the CCs'current clinical outcomes with outcomes prior to introduction of CBD's system designs and with those achieved with our redesign components. In addition, a quasi- experimental cohort design will document improvements in clinical quality and engagement of patients and care teams as clinics enhance CBD sequentially over the three year project. Intermediate outcomes will include provider and staff use rates of EMR best practice reminders and patient and care team adherence to CER-informed guidelines. Patient engagement will be assessed by patient use of our web portal, care manager supports, and adherence to personalized care plans. We will use our EMR and CBD implementation instrument to assess staff, provider, and patient behavior, and surveys of patient activation, experience with care, and quality of life, and of provider attitudes toward patient self-management to assess quality. An important goal of our project is evaluation of the impact of our interventions and strategies on clinic ROI. We anticipate changes in volume and related revenue for ancillary tests, services, and pharmacy as we manage the care needs of our high risk patients more effectively. We will evaluate the business case for implementing currently uncompensated components of care in our fee for service environment. Additionally, by using two unique state-wide databases, we will evaluate the impact of our redesign on total cost and cost effectiveness of care by measuring emergency department visits, hospital admissions, readmissions, and associated costs of care, demonstrating the potential for decreased costs of care in the broader community. These data are key to creating a business model for sustainability of enhanced CER-informed care. Our strong interdisciplinary research team ensures successful completion of this project. The team includes developers of CBD, clinician specialists in geriatrics and pharmacy practice, members with expertise in quality improvement, biostatistics, qualitative research, behavioral sciences, and economics, and a national advisory committee that includes leading experts in practice redesign and multi-methods evaluation. Results of this project will provide practical guidance for others seeking to implement CER-informed care in primary care practices. PUBLIC HEALTH RELEVANCE: This project specifically addresses the purposes of the grant program to demonstrate the feasibility and value of implementing evidence-based care improvement strategies and interventions in delivery systems as well as a number of objectives of Healthy People 2010 including improving access to comprehensive, high-quality health care services. This project implements a comprehensive program of care management for patients with multiple chronic conditions and evaluates the impact of transformation to a PCMH delivery model of primary care practices in a University network serving a broad patient population. The project addresses a broad goal for Healthy People 2010, to "Achieve access to preventive services for all Americans" by implementing best practices reminders in our EMR, pre-visit planning, and registry-based outreach.